OBJECTIVE:
To estimate the prevalence of physical violence and its association with sociodemographic
aspects, stressful life events, and the use of health services due to emotional
problems.METHODS: A cross-sectional population-based study was conducted with
a sample of 1,954 14-year-old or older inhabitants of the city of Canoas (Southern
Brazil). They were selected by means of conglomerate sampling according to a
pre-established system. Data were obtained in visits to households by means
of a confidential semi-structured questionnaire. A bivariate analysis was carried
out through multinomial logistic regression, and the multivariate analysis by
polytomous logistic regression, categorizing the outcome by age group.RESULTS: The findings show a prevalence of 9.7% (CI 95%: 8.37;11.03)
and association with: women 20 years old and older (OR=2.74; CI 95%: 1.52;4.94);
higher schooling rate (p<0.03); higher experience of stressful life events
at 20 years of age or more (OR=6.61; CI 95%: 2.71;16.1); and doctors' appointments
due to emotional problems as of 10 years of age (p>0.001).CONCLUSIONS: The prevalence of physical violence in the population was
significant, resulting in important emotional consequences and impact on health
services, requiring capacity building of the professionals in the field.

Violence is a global
concern. According to the Pan American Health Organization Steering Committee
(1993 and 1996), violence, in all its manifestations, is a public health priority
because it threatens the development of peoples and their quality of life.14
In Brazil, violence has been a constant topic in debates among those who represent
the population due to its repercussion in the quality of life, and the amount
of attention and healthcare it requires. However, according Minayo,12
although advances have been noticed, they are still insufficient to tackle the
problem.

Maltreatment encompasses
four categories: physical, sexual and psychological abuse, and negligence. Physical
abuse, in the present study, is called physical violence and is considered the
use of force or physical power, in the form of threat or bodily force against
a person, a group or a community. In most cases, it is accompanied by emotional
violence in the form of intimidation and verbal abuse.9

According to the
World Health Organization (WHO),9 more than two million people die
every year in the world due to the damage caused by violence. An even greater
number of people survive, but bear sequelae. Among individuals in the 15-44
age bracket, interpersonal violence is the third highest cause of death, accounting
for 14% of the deaths of men and 7% of women. The prevalence of physical violence
varies according to country (Paraguay 10%; Canada 34%), context studied, and
methodology used in data gathering. In regard to specific groups, the proportion
of women who have reported having suffered some type of violence (including
having been robbed) varies from 15.3% in Canada to 23% in England, and 25% in
Zimbabwe. The rate of adolescents who have been involved in physical fights
was 44% in the United States, 22% in Sweden and 76% in Israel. However, these
figures may be underestimated, since they are based on self-reports, which would
hamper a precise calculation of all kinds of violence in healthcare systems
and their effects in economic productivity.

Poverty is closely
related to the problem. A survey carried out in the city of Sorocaba (Southeastern
Brazil) between 1993 and 1995 showed that people in the sub-proletariat are
at a greater risk of suffering physical violence than those who belong to the
petit-bourgeoisie, non-typical proletariat, or typical proletariat.7
Age can also be related to violence: in Atlanta, in the United States, among
women who had experienced some kind of physical violence throughout their lives,
and who sought primary healthcare services, only 1% were older than 55 years
of age.21

In its most severe
form, violence can lead to death. It is estimated that 40% to 70% of female
homicides are committed by the closest male partner.7 In a study
with 1,172 women between 15 and 49 years of age, the prevalence rate was 27%
in the state of São Paulo and 34% in the state of Pernambuco.2

According to the
WHO, the emotional consequences associated to this problem can be physical,
sexual and/or reproductive, psychological and/or behavioral, and even fatal.7
The main emotional consequences are: anxiety, phobias, depression, post-traumatic
stress disorder, use and abuse of psychoactive substances including alcohol,
suicide attempts, among others.1,4,15 However, although the Brazilian
population suffers with problems related to violence, for most of these issues,
there is lack of Brazilian population-based studies.

In Brazil, the
official data available suggest that this phenomenon has been growing, mainly
in urban areas of large cities. In the field of pubic health, it is known that
violence has changed the mortality profile of the country in the 1980s, where
it went from the fourth to the second cause of death, preceded only by cardiovascular
diseases.13 However, a large number of violent events are not reported
to the authorities, thus being part of a "dark" figure, on which there is no
information whatsoever. In addition, many other forms of violence are not even
acknowledged by society and, consequently, are also not recognized by our institutions,
such as violence against children, adolescents and women. Even what is reported
has its setbacks, due to the poor filling in of forms where essential data for
clarifying events are not informed.

From the scientific
point of view, most national studies are carried out on specific groups such
as women and healthcare service users.15,18 Women, children and the
elderly who are victims of violence tend to seek more health-related appointments,
are hospitalized for longer periods, go to pharmacies more often, and have more
appointments due to emotional problems.9 These studies follow a standard
mainly focused on domestic violence.2,3,8

Therefore, the
present study aimed at estimating the prevalence of physical violence and its
association with sociodemographic aspects stressful events, and the use of healthcare
services due to emotional problems.

METHODS

This is a cross-sectional
population-based study part of a broader investigation aimed at studying several
aspects related to the health of the population in the city of Canoas6,a (Southern Brazil).

According to the
1991 population census, the only data available at the time the research project
was conceived; there was an average of 3.75 people per household in Canoas.
Therefore, to achieve the necessary sample size (3,858 subjects), 1,040 households
needed to be visited. Thus, 40 out of the 391 census sectors in the city were
randomly drawn, and 26 households per sector were randomly visited according
to a pre-established system between November 2002 and June 2003.

During fieldwork,
we surveyed less people than originally planned in the sample. There were, in
average, 3.2 individuals per household totaling 3,328 people. Out of the 1,040
households visited, 98 refused to participate: in 44 of them it was not even
possible to determine the number of people living in the household, and in the
remaining 54, the number of people varied from one to eight per household. There
were 615 individuals who were not interviewed because 410 refused to take part
in the study (66.7%), 189 were not home in three visits (30.7%), and 16 were
in no health conditions of being examined or interviewed (2.6%). In the end,
2,609 individuals belonging to all ages were surveyed corresponding to 78.9%
of the total possible number. There was a greater loss among men in the 25-49
age bracket.

Individuals aged
14 and older were considered the target population totaling 1,954 people. This
sample represents a loss of 20.3%, which satisfies a sample size capable of
estimating outcomes with prevalence between 10% and 40%, with 2.5% error and
significance level below 0.05.

The dependent variable
was the presence of physical violence during one's life. This variable was stratified
by the age bracket in which the violent event took place: non-occurrence of
physical violence (reference category); violence between zero and nine years
of age;violence between ten and 19 years of age; violence from 20 years of age
and above. The independent variables were: sociodemographic characteristics
(gender, age, income, living with partner); appointments due to emotional problems
(the term "nervous problems" was chosen to express this variable); psychiatric
hospitalization, and stressful events (unemployment, separation and robbery).

Data gathering
was carried out by means of a numbered questionnaire applied by a speech therapist
and a medical student, who received prior training. The section on violence
was filled in by the subjects themselves, and placed by them in a sealed envelope,
which was then placed in a sealed box, in order to avoid respondent being uncomfortable.
In this section, respondents answered whether they had experienced physical
maltreatment and, if so, at what age. For quality control, 5% of the households
were selected at random, and their members were interviewed by means of a second
visit or over the phone. Next, the concordance index was calculated for some
questions in the first and second interviews, obtaining kappa index of 0.93.
The questionnaires were numbered by the interviewers and reviewed by the coordinator
of the study. The data were entered by two research assistants in two separate
files and were later compared.

During data analysis,
a descriptive analysis was carried out first to measure the frequency of the
variables studied. Then, a bivariate analysis (Pearson's chi-square test) was
carried out to measure the association between the dependent and independent
variables, where p<0.05 was considered significant. To obtain the odds ratio
(OR), a confidence interval of 95% was considered. By using the nominal variable
physical violence categorized according to the age bracket during which the
violence took place, a multinomial logistic regression was used with the help
of Stata statistics program, version 8.0. Therefore, in the form of OR, the
association between each independent variable and the occurrence of violence
in the three age brackets was estimated, and the non-occurrence of maltreatment
was used as the reference category. Thus, the violence ORs in each age bracket
could be estimated at the same time, avoiding the use of multiple statistical
tests, and rendering proportional estimates, which were directly comparable,
and had a common reference category.

The research project
was approved by the Ethics Committee of the Universidade Luterana do Brasil
(Process 2004-055H), and all participants signed an Informed Consent Statement.

RESULTS

Women made up 57.4%
of the sample, 59.1% had primary school education, 38.7% were aged 20 to 39,
and 34.5% were aged 40 to 59, with income of 7.1 minimum wages or more (Table
1). In regard to using healthcare services, 475 respondents (24.4%) reported
having emotional problems, and 49 (2.5%) reported having a prior history of
psychiatric hospitalization. 95.1% of respondents stated they had not experienced
separation, or unemployment (83.9%), or mugging or robbery (90.2%) in the year
before the interview.

Physical violence
prevalence was found to be 9.7% (95% CI: 8.37;11.03), 57 subjects (2.9%) did
not provide answer to the question.

In the bivariate
analysis, the variables that presented statistically significant association
(p<0.05) with the outcome were: income, schooling, gender, stressful events,
appointments due to emotional problems, and psychiatric hospitalization.

In the multinomial
logistic regression (Table 2), the three
age brackets in which the physical violence took place were compared to the
non-occurrence of violence in life. Therefore, it was verified that among the
respondents belonging to the highest income group, the chance of their having
experienced maltreatment during childhood (zero to nine years of age) was higher
than when in the 10-19, and 20 and above age brackets. The opposite took place
among respondents in the intermediate income category (p=0.01). After 20 years
of age, it was observed that the higher the schooling rate, the lower the chance
of suffering physical violence (p=0.03).

The women presented
a significantly higher frequency (11.3%) than men (7.5%), with a 1.5 times greater
victimization risk (95% CI: 1.12;2.03). In the bivariate analysis, it was found
that boys aged 0 to 9 had chance two times higher for physical violence (38.5%)
than girls of the same age (17.3%). In the 20-29 age bracket, the opposite was
found: women had a higher prevalence (40.9%) when compared to men (21.2%). In
the multinomial regression (Table 2), among
female respondents 20 years and older, the chance of suffering violence increased
with age, their risk was 2.74 times higher than men's (95% CI: 1.52;4.94).

Respondents 20
years or older who reported experiencing two or more stressful events presented
5.85 times the risk of suffering physical violence (95% CI: 2.38;14.39).

Experiencing physical
maltreatment at any age bracket increases the chance of using healthcare services
due to emotional and/or psychiatric hospitalization (p=0.023 and p=0.05 respectively).
However, the two variables behave differently concerning the age of victimization.
Violence victims as of adolescence presented a three times higher chance of
having health-related appointments for emotional problems (95% CI: 1.60;5.87),
whereas childhood violence victims had higher chances of presenting hospitalization
history (OR=3.12; 95% CI: 0.92;7.80).

In the multivariate
polytomous regression (Table 3), at the first
level the variables income, schooling and gender were inserted. Income did not
present any association with maltreatment. Schooling and gender remained associated
to violence: having a higher schooling rate was a protective factor against
violence as of 20 years of age (OR=0.32; 95% CI: 0.34;0.95);being a woman meant
having three times the chance of experiencing violence in the 20 and above age
bracket (95% CI: 1.52;4.88). However, the difference between the categories
(age at victimization) in both variables did not prove to be significant (p=0.08
and p=0.09 respectively). At the second level, stressful events, appointments
due to emotional problems, psychiatric hospitalization, and living with partner
were inserted. Among these, only stressful events and appointments due to emotional
problems presented association to violence (p=0.0024 and p=0.000 respectively),
but in both cases the difference between the categories were not found to be
statistically different (p=0.72 and p=0.24 respectively).

DISCUSSION

Researchers in
health and social sciences are becoming increasingly more interested in the
study of violence, due to the great individual and social impact it causes.7-9
The present study included household visits during which respondents filled
out an anonymous self-applied survey, contributing to minimize a behavior which
frequently comes with the problem: silence. According to Krug et al,9
violence is usually underestimated or overestimated, specially violence stemming
from interpersonal conflicts in the family environment. Violence is underestimated
when the victims, mainly women and children, usually suffer in silence due to
shame of fear of retaliation coming from the aggressor; and it is overestimated
when data are gathered in health services or with government authorities (police
stations, forensic institutes).9 In the present study, the silence
may have been represented by the number of subjects who did not answer whether
they were victims of violence (2.9%), seeing that the survey was carried out
at respondent's household.

The 9.7% prevalence
found reveals the importance of the problem, and is different from prevalence
rates found in other locales. The difference is possibly due to the several
sources object of study, in an attempt to satisfy the goals and needs of the
institutions carrying out the research. In addition, prevalence rates are directly
influenced by the known limitations of the reporting systems, which are sometimes
difficult to compatibilize.12,13,21

The fact that violence
is not associated to living with a partner was not expected, seeing that domestic
violence is object of much concern, and affects women mostly.2,9,18
This result may be due to the methodology adopted (population-based), which
enabled the study of different population segments, some of which did not live
maritally, such as adolescents (13.4% of the sample). In addition, the variable
addressed the specific moment of the interview; therefore some of the respondents
could have been living apart from their partners, maybe even due to having been
victims of violence. Hence, this issue may be enlightened in future studies.

There was no association
for the income variable in the multivariate analysis. There is a possibility
that many of the respondents not knowing what was the exact family income and,
perhaps, the income variable forms a causal complex with schooling and gender,
thus losing its power. This hypothesis can be corroborated by the fact that,
to people with higher schooling rates, the chance of experiencing violence decreases
with age, thus schooling is a protection factor in the age bracket 20 and above.
These data confirm what was reported in other studies9,11,16 in which
poverty and low schooling rate are considered risk factors, mainly during adolescence.
Among the women who had appointments at a basic health unit (city of Porto Alegre,
Southern Brazil), 64% of the cases of violence occurred with women who had low
schooling levels, - revealing an inverse association with schooling years -,
and 48% of the cases were women who lived in favelas.8 However, respondents
with higher schooling levels are the ones who revealed more chances of having
experienced maltreatment during childhood. Although the difference among age
brackets was not statistically significant, the number is a warning against
the increasing number of children who are victims of violence, including in
the school environment.5 Even so, since education is a protection
factor, the present study corroborates a WHO9 recommendation concerning
the need of improving schooling rates as part of global and inter-sector policies,
which are essential for fighting violence.

As expected, the
relation between violence and gender was confirmed in the present study, and
women, in general, are the main victims. However, the male group showed an association
with childhood violence. The differences in the distribution of violence according
to age and gender did not present statistical significance. This fact should
be considered a limitation of this study, due to the loss of male subjects in
the 25-49 age bracket. Violence against children, specially boys, can be explained
by cultural elements, according to which physical punishments are considered
a form of exerting discipline, justified by the need to protect them from dangers
or to make them become "good" adults.11,10,19,20 It is also possible
that this violence mirrors a form of parental negligence, since the different
forms of violence and acts or omissions that lead to death make up the nucleus
of the main factors responsible for pushing children away from home or having
them removed from the family environment, thus exposing them to other forms
of violence in the streets or in shelters.5,9 Aggressive children
normally live in an aggressive home, because the parents are the children's
main role model, thus governing the development of aggressive behaviors in their
children.3 A boy who was a victim of aggression during childhood
may grown into an adult who repeats this action within his family, copying the
model learned, thus forming a violence cycle which is difficult to break. Overcoming
this problem requires inter-sector and interdisciplinary strategies, where the
building of an epidemiological database plays a fundamental role and, to which,
these findings can contribute.

Maltreatment, both
in children and in adults of both genders, has important emotional consequences
associated to a worse perception of one's health, higher usage of legal and
illegal drug, depression and post-traumatic stress disorder. The impact of these
actions does not only affect the individual, but also society, mainly the health
system.9,14 This can be evidenced by the present study, where it
was found that those who experienced violence made more appointments at health
services due to emotional problems. However, the association with psychiatric
hospitalization, shown in the bivariate analysis but not confirmed in the multivariate
analysis, may mirror a limitation of this study, because the number of subjects
who reported being hospitalized was small (n=49), which affected the analysis.

In any case, the
data corroborate findings of other authors8-10,21,22 according to
whom providing care to the victims requires an adequate structuring of the health
system in order to give the victims the proper attention in a dignified way:
to diagnose violence and meet the demand. In this fashion, the activities carried
out by the Family Health Program and the Community Health Agents must be integrated.
However, this leads to reflect on the extent to which the Brazilian health system
and Brazilian professionals are prepared to identify and address the problem.
In a qualitative study21 it was found that many primary healthcare
providers (doctors, nurses and assistants) find it difficult to deal with the
problem, stating that aspects related to the victim, lack of knowledge and adequate
skills were the main obstacles. Taking this into account, we notice a positive
perspective in the capacity building of these professionals, since education
institutions are promoting courses for managers and health professionals aiming
at filling this gap. 12

In regard to stressful
events (unemployment, robbery, and separation), the present study found an association
between physical violence and the occurrence of two or more stressful events
in subjects in the 20 years and above age bracket. Even when considering the
limitations of this study (temporality and cross-section), the results can give
evidence of a kind of social environment in which several kinds of violence
converge, and one that is structured in such a way as not being able to protect
the population from the dire consequences of violence.17

In conclusion,
physical violence is a complex problem, which violates human rights, and has
biopsychosocial roots that deserve to be treated as a collective health problem.
Collective health policies should include interdisciplinary actions and global
political will to fight: poverty; interpersonal conflicts (mainly those stemming
from within the family system), intake of psychoactive substances, specially
alcohol, and should aim at providing training to the human resources in the
field of primary health care so these professionals are capable of identifying
the problem, and acting adequately to help solve it.